A nurse is caring for a client who is pregnant in a provider’s office.
Relevant vital signs to help answer the questions are as follows: Medical History: 0830 Gravida 3 Para 2, 32 weeks of gestation, Allergies: Penicillin, Height: 163 cm, Weight: 78 kg, BMI: 30.6, 6 lb weight gain over the last 2 weeks.
The client reports “I have had a headache for 5 days, blurred vision, and dizziness. Tylenol does not relieve it.” The client reports swelling of their feet and fingers.
2+ pitting edema of the lower extremities noted bilaterally. Swelling of the fingers and hands noted.
Deep tendon reflexes 3+, absent clonus.
Fetal heart tones (FHT) 1. Which of the following findings should the nurse report to the provider? Select all that apply.
Visual disturbances.
Fetal heart rate.
Blood pressure.
Deep tendon reflexes.
Correct Answer : A,C,D
Rationale for Choice A: Visual disturbances
Preeclampsia: Visual disturbances, such as blurred vision or seeing spots, can be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and protein in the urine. It typically develops after 20 weeks of gestation and can progress rapidly.
Potential complications: If left untreated, preeclampsia can lead to seizures (eclampsia), stroke, liver and kidney failure, premature birth, and even death of the mother or baby.
Prompt reporting: Early recognition and management of preeclampsia are crucial for preventing adverse outcomes. Therefore, visual disturbances should be reported to the provider immediately to initiate further assessment and potential interventions.
Rationale for Choice B: Fetal heart rate
No indication for reporting: While monitoring fetal heart rate is essential during pregnancy, the promptness of reporting it to the provider depends on specific concerns. In this case, the fetal heart tones are documented as 1, suggesting a normal rate and rhythm. There's no immediate indication for reporting it as a concerning finding.
Rationale for Choice C: Blood pressure
Hypertension: High blood pressure is a key feature of preeclampsia. Although blood pressure readings are not provided in the scenario, the nurse should measure and report them to the provider, as hypertension is a critical finding that could necessitate further evaluation and treatment.
Rationale for Choice D: Deep tendon reflexes
Hyperreflexia: The client's deep tendon reflexes are 3+, which is considered hyperreflexia. Hyperreflexia can be a neurological sign of preeclampsia, indicating increased excitability of the nervous system. It's important to report this finding to the provider for further assessment and monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The estimated date of delivery (EDD) using Naegele's rule is _.
Step 1: Add 7 days to the first day of the last menstrual period. May 8 + 7 days = May 15
Step 2: Count 3 months back. May - 3 months = February
Step 3: Adjust the year if necessary. The year remains the same.
The estimated date of delivery is February 15 of the following year.
Correct Answer is C
Explanation
Choice A, 42022:
This option incorrectly counts the elective abortion as a term birth. Elective abortions, regardless of gestational age, are not considered term births in the GTPAL system. They are classified under abortions (A).
Including the elective abortion as a term birth would overestimate the client's parity, leading to inaccurate assessment of her reproductive history.
Choice B, 20022:
This option incorrectly excludes the elective abortion from the GTPAL calculation. Elective abortions are considered pregnancies and are included in the gravida (G) count.
Omitting the elective abortion would underestimate the client's overall pregnancy history and potentially overlook relevant factors related to her reproductive health.
Choice D, 20222:
This option incorrectly counts the spontaneous abortion as a preterm birth. Spontaneous abortions that occur before 20 weeks of gestation are not classified as preterm births in the GTPAL system. They are categorized as abortions (A).
Classifying the spontaneous abortion as a preterm birth would misrepresent the client's obstetric history and potentially lead to inappropriate care decisions.
Choice C, 40122:
This option accurately reflects the client's parity based on the GTPAL system:
Gravida (G): 4 (total pregnancies, including elective abortion, spontaneous abortion, twin birth, and current pregnancy) Term (T): 0 (no previous term births)
Preterm (P): 1 (twin birth at 36 weeks, considered preterm as it occurred before 37 weeks) Abortions (A): 2 (elective abortion and spontaneous abortion)
Living children (L): 2 (twins from the previous pregnancy)
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